1. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

2. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. in the clinic Contraception

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4. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are most likely to become pregnant unintentionally?  Women <19 years old  80% teenagers describe their pregnancy as unintended  Women with low educational attainment or low income  Income 200% above it

5. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are most likely to become pregnant unintentionally?  Black women have highest unintended pregnancy rate  > 2x that for non-Hispanic white women  Type of contraception may play role  Hormonal methods = 2x higher rate of pregnancy vs. long- acting reversible methods (among adolescents)

6. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the various types of contraceptives and how do they work? Hormonal methods  Combined (ethinyl estradiol + progestin)  Oral contraceptive pills (COCs): daily by mouth  Transdermal patch: single patch weekly for 3 weeks, then off for week (for withdrawal bleed)  Vaginal ring: ring inserted in vagina for 3 weeks, then removed for a week; new ring each month

7. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the various types of contraceptives and how do they work? Hormonal methods  Progestin only  Oral contraceptive “mini-pill”: daily by mouth with no “off” week  Injectable: IM injection every 3 mo by health care provider; SQ may be self-injected

8. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Long-acting reversible contraception methods (LARC)  Hormonal and nonhormonal  Subdermal implant: placed in upper arm by trained OB/GYN; used ≤3y  Levonorgestrel (LNG-IUD): placed in uterus, used ≤5y  Copper IUD: placed in uterus, used ≤10y

9. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Barrier  Nonhormonal  Male, female condoms: protect against STDs; available OTC  Vaginal sponges: Available OTC  Diaphragm; cervical cap: must be fitted by a physician

10. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. How effective are contraceptives?  Permanent sterilization and LARC: top tier methods  Vasectomy: failure rate 0.01%  Female sterilization: failure rate 0.5%  Copper IUD: failure rate 0.8% at 1y  LNG-IUD: failure rate 0.1% at 1y  Subdermal implant: failure rate 0.05%  Combined Oral Contraceptive pills, patch, ring, DMPA injection: next tier methods  Efficacy influenced by adherence  COCs: perfect use failure rate 0.3% vs. typical use rate 8%  DMPA injection: failure rate 3%  Barrier: lowest tier methods  Efficacy limited by user compliance  Typical-use failure rates ≈15% All better than nothing… 85% of reproductive-age women having regular unprotected sex pregnant within 1y

11. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What is meant by “emergency contraception”?  Any contraception method used after sexual intercourse  Doesn’t disrupt an established pregnancy  Levonorgestrel (Plan B, Plan B One-step)  Levonorgestrel 0.75 mg (2 pills) or 1.5 mg (1 pill) within 5d of unprotected intercourse  Reduces risk for pregnancy by 89%  Efficacy decreases slightly each day after unprotected sex  Available without prescription if ≥17 years old  Ulipristal (ellaOne)  Ulipristal acetate selective progesterone receptor modulator (30 mg pill, given once)  Reduces risk for pregnancy by 90%  Maintains efficacy through days 1 through 5  By prescription only

12. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1.  Copper IUD  Inserted up to 5 days after contraceptive failure/nonuse  Reduces pregnancy risk by 99% (most effective method)  Patient should desire the device for contraception  Alternative: COC pill regimen  Number of pills varies depending on pill formulation  Compared with other options: more side effects, less effective, and must be taken within ≤72 hours

13. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What is the role of tubal ligation and vasectomy in contraception?  Sterilization considered permanent  Patients should be certain they don’t want more children  Reversals are costly and frequently unsuccessful  Procedure carries surgical and anesthetic risks  Vasectomy more effective than tubal ligation + safer (however patient not sterile until ≈12 weeks after procedure)  LARC methods: may be more appropriate option  Subdermal implants or IUDs  As effective as sterilization for reducing pregnancy

14. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Epidemiology and Efficacy…  50% of pregnancies in U.S. unplanned  Poor, young, or minority women at highest risk  Contraception can prevent unplanned pregnancy  Most effective: IUDs, subdermal implants, and sterilization  User error adds to higher failure rate (≥10%) for pills, patch, DMPA injection, vaginal ring  Emergency contraception options  Copper IUD most effective

15. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are there beneficial effects to the use of contraception beyond pregnancy prevention ?  Combined hormonal methods (the pill, patch, or ring)  Alleviate dysmenorrhea  Control cycle  Reduce endometrial hyperplasia  Improve menorrhagia symptoms  Prevent premenstrual dysphoric disorder  Reduce hirsutism and acne  Decrease endometrial, ovarian, & colorectal cancer risk  Improve symptoms exacerbated by hormone fluctuations

16. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1.  Injectable contraception  Improves menorrhagia symptoms  Reduces endometrial cancer risk  Control cycle (if comfortable with amenorrhea)  LARC methods  Benefits similar to COCs  Subdermal implant and LNG-IUD: improve menorrhagia, and dysmenorrhea and other symptoms of endometriosis  LNG-IUD and copper IUD: decrease endometrial cancer risk  LNG-IUD: treat endometrial hyperplasia without atypia

17. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the risks for combined hormonal contraceptives? All combined hormonal contraceptives (≤35 mcg estrogen):  Venous thromboembolism  Slightly elevated risk (most common in 1 st year use)  Slightly higher for older women and obese women  Risk eliminated in ≤30d of discontinuation  Transdermal patch: black box but risk not higher  Hemorrhagic stroke, ischemic stroke  Increased risk if patient has uncontrolled hypertension, migraines with aura symptoms, or smokes  All combined methods contraindicated in these women  Arterial blood clot  Increased risk if smoker, >40 years old, obese

18. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the risks of progestin-only and LARC methods? Injectable medroxyprogesterone acetate  Weight gain ( ≈5.4 pounds)  Loss of bone mineral density  Transient and reversible; no increased fracture risk Intrauterine devices  Cramping in 1 st few months (more common w/ copper IUD)  Treat with NSAIDs  Spontaneous expulsion (risk <1%)  Genital tract infection at time of insertion  Prophylactic antibiotics don’t decrease risk  Uterine perforation at insertion (very low risk: 0.01%)

19. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the risks to the fetus if pregnancy occurs when a woman is receiving oral contraceptives? No risks  No evidence of  fetal anomalies spontaneous miscarriage preterm delivery birth defects compromised fertility of offspring

20. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Medical Considerations…  Medical benefits of hormonal contraception  Cycle regulation, lighter periods  Reduced premenstrual symptoms  Medical benefits of LNG-IUD and subdermal implant  Decreased menstrual bleeding  LNG-IUD only: improves endometrial hyperplasia  Medical risks of hormonal contraception  Stroke: contraindicated if >35y old & smoker, or if migraines + aura  VTE: slight increased risk (highest in first year of use)

21. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. When should women be counseled about contraception?  Before first sexual encounter  Average age of first sex in United States is 17  Repeat throughout reproductive years  Average U.S. woman spends 5 years attempting pregnancy, being pregnant or postpartum  Spends nearly 30 years avoiding pregnancy

22. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are at greatest risk for complications if they become pregnant?  Breast cancer  Complicated valvular heart disease  Diabetes (especially type 1)  Endometrial or ovarian cancer  Epilepsy  Hypertension  Bariatric surgery in past 2y  HIV/AIDS  Ischemic heart disease  Malignant gestational trophoblastic disease Medical Conditions Increasing Risk for Complications

23. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are at greatest risk for complications if they become pregnant?  Malignant liver tumors, hepato- cellular carcinoma of liver  Peripartum cardiomyopathy  Pulmonary hypertension  Schistosomiasis (liver fibrosis)  Severe cirrhosis  Sickle cell disease  Solid organ transplantation  Stroke  Systemic lupus erythematosus  Thrombogenic mutations  Tuberculosis Medical Conditions Increasing Risk for Complications

24. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. How does this affect their choice of contraception?  Encourage use of most effective method to decrease possibility of a risk  Often: LARC or sterilization (if finished childbearing)  Consult U.S. Medical Eligibility Criteria, from CDC  Comprehensive analysis of medical problems and risks associated with certain contraceptives  Helps determine which methods a patient could use

25. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. How should women go about choosing an appropriate contraceptive?  Lifestyle  Unpredictable work schedule? may be hard to take pill at same time every day  Planning future pregnancy?  STD protection? Condoms prevent pregnancy + STDs  Past use  Unplanned pregnancy when using contraception in past?  Unable to continue a method in past? (unlikely option)  Side effects  Such as spotting with subdermal implant  Personal comfort  Discomfort changing a vaginal ring? (will discourage use)  Discomfort with amenorrhea from LNG-IUD ?

26. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are there forms of contraception a woman should avoid if she is considering pregnancy in the next year or so?  Injectable medroxyprogesterone acetate  Delayed return of fertility (≈10 months)  Not recommended if desiring pregnancy in near future  Other contraception methods allow rapid return to fertility (IUD, subdermal implant, combined hormonal)

27. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What contraceptives can breastfeeding woman use?  If breastfeeding  Progesterone-only methods acceptable, safe  Can be started immediately after delivery  Delay estrogen-containing methods until 6 weeks post- partum and lactation well-established (elevated VTE risk)  Option: barrier method (refit diaphragm / cervical cap after delivery)

28. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Counseling Considerations…  Initiate contraception counseling before first sexual activity  When choosing appropriate contraception…  Consider patient comfort, lifestyle, past method use  Medical conditions (may increase risk for complicated or dangerous pregnancy)  Consult CDC Medical Eligibility Criteria  Be aware return to fertility delayed after discontinuing injectable medroxyprogesterone

29. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the cost and cost-effectiveness of contraception? All more cost-effective than unwanted pregnancy Cost  Combined methods: $8 - $80 per month  Medroxyprogesterone: $35 - $75 every 3 months (plus nursing visit for administration)  LARC methods: $300 - $800 without insurance Cost effectiveness  LARC and sterilization: highest up-front cost  But most cost-effective over time  Combined methods: less cost upfront but refills required  Less cost-effective given decreased efficacy vs LARC  Condoms: least cost-effective (b ut protect against STDs)

30. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are all forms of contraception covered by most health insurance plans?  Most insurance companies cover contraception  If there is a prescription drug benefit  Pa tient Protection and Affordable Care Act  Requires insurers to cover contraception without copay  Plans that existed when PPACA passed grandfathered in  Any significant changes or modifications to plans will mandate adoption of the new regulations  Exemptions for some religious employers

31. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Cost Considerations…  Most cost-effective form of contraception: LARC  Cost of contraception: covered by most insurance plans that include prescription drug benefit  PPACA: requires all insurance providers to cover contraception without copay

32. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Should primary care physicians prescribe contraceptives or should they refer patients to other providers?  For medically uncomplicated women: Primary care physician may prescribe contraception  However few are well-trained in contraception provision  PCP often first-line providers for ill women, who may need counseling about contraception  Especially important if also prescribing teratogenic medication  For women with medical problems: refer to OB-GYN or family planning specialist

33. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are there programs to train internists in providing contraception?  Most training occurs during residency / fellowship  Subdermal implants: Manufacturer can provide formal training on placement  IUDs: Consider contacting local provider within your institution for training on insertion  In general, refer patient to experienced person for counseling and fitting of device  OB-GYN or family practice physician or nurse

34. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Provider Considerations…  To prevent unintended pregnancy: provide contraception to all sexually active reproductive-age women  Internists should feel comfortable and responsible discussing contraception with patients  Especially if medically complicated  Refer to OB-GYN or family practice physician if patient has:  Medical problems, an interest in LARC method, or if there is difficulty identifying appropriate method